Extra fees may save private practice primary care

I was interested in an article in USA Today about the growing number of physicians, especially primary care doctors, who are boosting their revenues by requiring patients to pay new fees for services that insurance doesn’t cover.

No longer is your insurance payment “all-inclusive”. These fees can include annual administration fees, no-show fees, medical report fees, and extra fees for email or phone consultations. If private practice medicine is going to survive, these fees are a necessity.

An article in the NEJM in April, showed how much time physicians spend on activities that receive no compensation at all. It is not unusual for an internal medicine physician to spend an extra 3 hours a day filling out forms, refilling prescriptions, making phone calls on patient’s behalf, answering questions from patients and dealing with a myriad of patient related requests. With overhead running at 65% or above, more and more doctors are leaving practice or burning out. The ones who can, are joining large hospital sponsored groups where they are subsidized. These groups know that primary care is a “loss leader” for the more lucrative procedures that insurance and Medicare reimburses.

As a physician who has practiced for over 20 years, I can tell you that the demands of filling out forms for everything from work questions and school physicals to handicapped stickers and travel vouchers, dealing with insurance companies, reviewing tests ordered by other doctors, overseeing and coordinating patient care, talking with pharmacists, filling prescriptions and then redoing the work when a patient switches pharmacies, emailing and countless other tasks that are “free” make it near impossible to remain in private practice.

What makes sense for primary care? Instead of nickel and diming patients, there should be an annual administration fee that covers these extras. Just like your car insurance doesn’t cover the oil change, health insurance doesn’t cover the tasks physicians perform on your behalf. How much of an annual fee depends upon the practice. For most practices $125/year should cover the extras.

I think most would find that a small price to pay to keep their doctor’s doors open.

Extra fees may save private practice primary care 46 comments

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The Happy Hospitalist

That’s interesting. I just wrote a piece yesterday about how E&M codes are actually failed bundled care experiment and how it’s time to decouple what we docs do in E&M and start charging for every aspect of the care we provide from fees for writing prescriptions to fees for preauthorization. If bundled care is going to work, it must be paid for.

Don’t most businesses have overhead tasks that the staff perform that doesn’t get directly compensated? Lowe’s sells lawn mowers at a price that builds in their cost for providing a friendly, helpful person who can help you pick the right one, call to assure that there is stock, arrange to have it assembled, and help you get it in your car.

Fees like the ones you describe are akin to baggage fees on airlines. People understand that the fee used to be built into the price of the flight and that now the cost is just being presented in a different way. My thought is: what’s the point? How are patients going to respond to paying a fee for each email. Realtors and other freelancers type hundreds of emails, meet with clients and take hundreds of phone calls without charging for them. Why should doctors. There definitely is a problem but this doesn’t seem like the solution.

BladeDoc

Yes but Lowe’s can raise either: 1. raise the price on their lawnmower to cover their overhead + profit or 2. lower their overhead. Physician’s prices are fixed by the government (basically, we can quibble about arguing with insurers but realistically we all know it’s medicare +/- some small percentage) and our overhead is relatively fixed because of regulatory requirements. Pretending that physicians work in some sort of free market is delusional.

Very tempting. Do these practices have a policy of “charity” care for those who cannot pay this fee, or is it hard and fast? Do they accept government payers? Is this legal with medicare and medicaid? I’d love to see a post or article somewhere with all these details.

Keegan Duchicela

This is legal with Medicare and Medicaid because the fee is for uncovered services.

Larger groups and foundation models like the Palo Alto Medical Foundation near where I live charges 5$/month for email access.

These fees are going to be standard in the future.

To comment on Villalobos question “What’s the point?” Patients may initially respond by delaying outpatient medical care because the feel like they don’t want to be ‘nickel and dimed’. But fees like this are necessary to sustain primary care. Think it’s hard finding a doctor for a Medicare patient now? Just wait 5-10 years. Then it will be really bad. Those of us in the medical field worry that when we reach Medicare age, there will be no one left to take care of us. It’s nice to imagine that NP’s and PA’s will fill in the primary care void, but reality is that many of them are transitioning to specialty fields as well. And Medicare patients can be really complicated: poly-pharmacy, multiple comorbidities. Most of these people are really better served by a proficient MD or DO, family practitioner or internist.

But that’s a digression. Even for those who feel that NPs will fill the primary care void, they’ll charge these fees as well.

ninguem

Don’t most businesses have overhead tasks that the staff perform that doesn’t get directly compensated?

And with medicine, every year it’s more, and more, and more.

MB

Sounds likes like the airlines…Perhaps doctors offices should charge patients for using the bathroom.

I once had a roommate that had to pay a fee to talk to a bank teller about her account.

Is this how you doctors really want to practice medicine? Are you going to disclose every dime to the patient, “You need this lab work and I will charge you $5.00 to tell you the results.”

Vox Rusticus

Of course it isn’t the way most doctors want to practice medicine. We want to get paid properly for all of the work we have to do. But patients want to fob off the responsibilities for payment to Medicare and insurers, who themselves have their own agendas or profit incentives that cause them to limit payment.

You can’t expect to get the same service for less money. And since professional standards govern what we must do in patient care, it only makes sense that we ever more closely define what is essential professional service from what is additional non-clinical administrative service.

History taking and physical examination and face-to- face discussion is clinical service. So are procedures.My office staff salaries and office rent and utilities are overhead. Filling out someone’s disability insurance paperwork is neither clinical work nor is it necessary overhead for my operations. It is extra, non-clinical work for which any other professional would think it justifiable to charge for professional time used to fill it out. The same goes for time spent writing to doctors and others that have not consulted me but who the patients want correspondence sent just for FYI purposes, and forms filled out for employers and materials sent to lawyers involved in disability claims and other matters not related to my practice.

Patients should understand that professional time should be paid for, and just because your boss, or benefits manager or lawyer or insurance adjuster hands you a form and says “have your doctor fill this out and return it” doesn’t mean I have an obligation to do that kind of thing for free. And no, whatever your carrier paid for an office visit at some other time or for some other reason does not create an obligation on my part to do paperwork without charge at some other time.

MB

I got a pay cut this year, and I do the same job I always did.

I do understand professional service and I am willing to pay for services rendered. I also understand that insurance and government payments aren’t fair to primary care physicians. It seems odd that the solution is to treat patients with contempt. You think that $40 copay is the only medical expense I have. I dole out $12,000 of my own money for “free” medical care.

r watkins

Asking you to pay for an administrative service provided is “treating you with contempt”? I think the contempt is all on the side of a patient who demands that a doctor work for free.

MB

–Asking you to pay for an administrative service provided is “treating you with contempt”?

So what are you going to charge me for making an appointment? Should I bring my own gown next time and a specimen jar?

So you think the way to get paid more is to nickel and dime your patients?

I belong to a CSA, the main reason is to support my local community. I pay more for food than I would buying from a chain grocery store. I think it’s worth it. I would have no problem supporting a local doctor in the same way, one that part of the community, and I would pay more for such a service. I don’t want to be nickeled and dimed. It’s amazing how the medical profession has no backbone to stand up for themselves and say no to inadequate payments.

Primary Care Internist

that $12,000 premium and what that covers, well that’s between you and your insurer. If they pay out $60 to your doctor to see you, and you see him/her 4x/year, that’s $240, or about 2% of your premium. Think about where the other 98% of your money went. Really, just look at your statement next time.

So if your doctor doesn’t feel that’s enough to include stuff that used to be “free”, then go find someone else! I don’t think your doctor is treating you with contempt just by trying to keep his doors open. Remember that doctors are small businesspeople, having to juggle your crappy insurance payments (which haven’t risen EVER for me, and over which I have NO negotiating power) with rising practice expenses.

It’s a wonder to me that ANYONE takes certain insurances (medicaid, GHI, HIP, BCBS, Oxford freedom, etc.), and I think in 5yrs we’ll probably see the MAJORITY of major multispecialty practices dropping them also, along with medicare or obamacare or whatever becomes of a massive new entitlement.

MB

“that $12,000 premium and what that covers, well that’s between you and your insurer. If they pay out $60 to your doctor to see you, and you see him/her 4x/year, that’s $240, or about 2% of your premium. Think about where the other 98% of your money went. Really, just look at your statement next time.”

It seems that everytime primary care is discussed, only the primary doctor’s fee is relevant. That $12,000 pay for a safety net if one of my family is seriously injured or ill. It includes treatment for cancer. Without it, I would not be able to afford treatment for serious disease. It also pays the $3,000 I need in medication and the frequent lab visits to monitor the effects of medication. I pays for well care for my entire family. It paid for the ADHD evaluation for my son. It paid for my spouse’s hospitalization last year…and he would have refused to go and taken his chances if we had to pay the $20,000. It paid for the specialist I saw last week and will pay for the procedure he recommended. A few years we have received more benefits than the $12,000 but most years it just provides that safety net-just like my homeowners insurance and my car insurance.

The contempt comes from this constant dialogue that patients get “free” care that they don’t deserve. My insurance allows about $150 for a 15 minute visit. This has steadily increased over the years. It requires no referral forms, no preauthorizations. More contempt because the person with the appointment before me had Medicare. If you want to blame me for your financial woes, don’t expect any support-I’ll express my generosity elsewhere.

Primary Care Internist

MB, I think for most insurances doctors are doing patients a tremendous favor by accepting insurance assignment, basically gambling on if and how much they’ll be paid.

Is there ANY other industry where a small business is so altruistic?

Doctors need to start growing some balls already.

ninguem

“You need this lab work and I will charge you $5.00 to tell you the results.”

It’s more like “I got these lab tests at a free community screening, or paid one of those traveling road show screening fairs”. Now I have results I don’t understand, and I want you to explain it all to me. For free over the phone. On a Sunday afternoon.

I treat opiate dependent patients. The cost of my office visit, labs, and the drug itself cost what the patient spent for two days of their illicit drugs. Yet they still bitch at me about the bill. They’ll pay their drug dealer, they won’t pay me to get them off the drugs.

MB

This is the contempt I am talking about. I don’t behave this way. If you want me to take my business somewhere else, go ahead and use your nickel and dime scheme. I schedule extra time when needed so my doctor will get paid for my complicated issues. I would make an appointment if I needed a form completed. I understand your administrative costs and try to respect that. I don’t get the same respect back. I don’t want your contempt because you don’t get paid enough. I’ll stop having any consideration for my doctor’s time because in the end, he thinks I am some drug addict looking for handout. Good luck with your fees. I’ll look elsewhere for healthcare.

Vox Rusticus

“I’ll look elsewhere” . . . . for some other doctor who I can let my insurance company chisel down whilst I pretend that extra administrative work is a burden someone besides myself should pay for.
. . .
“Good luck with your fees. I’ll look elsewhere for healthcare.”

So it really is about the fees. Your complaining that doctors are showing “contempt” is ironic, since you object to being charged fees for services you expect but that your insurance company doesn’t pay for and never did.

That is called having a sense of entitlement, and an unjustified one at that.

MB

“I’ll look elsewhere” . . . . for some other doctor who I can let my insurance company chisel down whilst I pretend that extra administrative work is a burden someone besides myself should pay for.

I didn’t say that, you did. I never said anything about doctors not being compensated for their time. Now I am entitled…and there is no contempt here.

Anonymous

dear MB,
you wrote:
“If you want me to take my business somewhere else, go ahead and use your nickel and dime scheme. I schedule extra time when needed so my doctor will get paid for my complicated issues.”

YOU ARE NOT GETTING THE POINT.
here it is: EVEN if you schedule “extra time” for your appt, your primary care doctor is NOT GETTING PAID ENOUGH to pay his bills. do you have any sugggestions for this problem? its very real and very serious. im a primary care doctor in private practice and im leaving it 3 months due to poor pay. YES FOR REAL: LEAVING. I CANT PAY MY BILLS. can it be made it any more clear? how do you feel now that i have informed you that you did NOT PAY ENOUGH for your doctors visit? will you dare to address that concern?

please join the debate with some solid and realistic solutions to address this or you may someday be getting the letter i have been drafting for my patients that goes something like this:

Dear Esteemed Patient:
due to the high cost of running a practice and the low reinbursement by your insurance company, i will be closing my practice. please find another primary care physician.”

sincerely,
a PCP

MB

1. Universal health care with a salary for primary care.
2. A standard fee, paid for by the government, insurance companies or patients that would cover basic primary care…office visits, x-rays, common labs…no need for billing…some have suggested vouchers…there was a commenter on this blog that suggested $600 per patient.
3. Membership into a medical cooperative where a patient pays premiums to a multispecialty group and the group takes care of them. Partnering with personal trainers and nutritionists would be a plus. Set it up as a non-profit with a board of directors. Perhaps a feeling of community would motivate members to keep costs down by staying fit and eating well.
4. A cash only practice.
5. Contracting only with insurance companies that pay enough.
6. Work with your community leaders to set up a non-profit charity to help cover the cost of low reimbursements for private practitioners…much like the foundations hospitals use.
7. Abandon the all the stupid codes owned by the AMA and advocate for real reform, not just bigger reimbursements for a failed system.
8. Nickel and dime your customers to get every dime you can. Itemize every needle, bandaid, specimen slide. Blame patients that their expensive insurance isn’t enough and that they need to pay even more. Continue to contract with insurance companies that don’t pay you enough so you can blame powerless patients for poor reimbursements.
9. Complain that the government, the insurance companies and patients are a bunch of losers and that you have no choice but to live in poverty.

I don’t have a primary care doctor at this time. I have been seeing a nurse practitioner for those little things that need attention. She even e-mails me. When it gets to the point where the nurse practitioner doesn’t meet my needs, I will pay cash to a Naturpathic Physician for those basic things. I wish the government would deregulate presciption medications so I could treat myself.

fam med doc

i treat oppiate addicts too. you must mean with buprenorphine. may i ask what you charge? currently i charge $130 for the new eval H and P, $350 for the 2 day office detox protocol which i typically seperate from the new H and P, and $100 for the monthly follow-ups. im in los angeles. i thought 2 years ago when i first obtained my buprenorphine license that there would be a tremendous demand for such services, but i am very under-whelmed. i currently have about 6 patients who come every month. i might have another 3 who come in sporadically. there seems to be a significant competition from doctors in los angeles for cash paying buprenorphine patients. i think this lowers the what doctors office charge, but i have been unwilling to lower my fees to date due to principle. if im going to see a drug addict and help them get off their herion, i feel i should be paid what it costs me to keep my office open and pay bills. what do you charge for your office buprenorphine program?

Primary Care Internist

This thread just shows that patients:

a) don’t understand that our fees are NOT AT ALL determined by us or free market forces; and

b) have a tremendous sense of entitlement.

The inevitable shortage of PCPs (including mid-levels) will only further empower doctors who do manage to swallow the daily crap of running an office, to play by our own rules for a change. And screw medicare and private insurers and Obamacare – they’ll all become just like medicaid – “insurance” without actual medical care.

DO Student Doc

True that, PCI. There are a lot of assumptions floating around with little to no basis in reality. Patients need to spend a bit more time educating themselves as to what their insurance actually pays for and exactly how their doc gets paid. Of course, most insurance companies really don’t want this information to be known as most people wouldn’t like the way their insurance is treating their friendly neighborhood family doc.

In the end, I think that something like boutique medicine (charging an annual “maintenance fee” to be part of a doc’s practice) is where things will be heading. It’s about the only idea on the table that allows docs the flexibility to actually care for their patients the way they want to and still get paid a fair wage. Like most small business owners, primary care docs just want to pay their bills, pay their staff a fair wage and still feed their families.

jo

$125 a year? What other secondarily educated professional would devalue their expertise such? I added up the non-paid services of reviewing questionnaires, reviewing medications and refilling prescriptions, education and counseling and multiplied that by a $350 an hour professional hourly fee and came up with about $1500 in uncovered services…on just the annual exam alone. Now multiply that by other visits that require explanation, coordination of care which utilizes your professional training and experience and you have to then wonder why have physicians have allowed those that sit in their ivory towers to define our worth. Why haven’t there been more “unionization” and protest from physician groups? Are the physicians so benevolent that they really will work more and more for free? If so the powers that be will allow you to do just that. I say at least $1000 a year for uncovered services is required to raise the professional respect in the eyes of patients and decision makers. If physicians take themselves for granted so will others.

bw

Well the $125/year is the only free market price a physician could set since he has little control over reimbursements… if someone wants to charge $1000/year flat fee, and a patient finds it worth $1000/year to have a physician be more prompt, continue taking medicare, etc, then that’s fine also. Inevitably some patient will not want this, and they will find a new doctor. That’s fine too.

There is so much hostility on both sides, with patients feeling the financial strain of an inflating health care system, and physicians defensive about struggling to survive in a system that sucks. Hopefully we can all take a deep breath and get along while we figure something out. I’m, personally, in favor of people dealing with their own insurance companies for primary care stuff. I think we’d all figure out really quickly what the problem is.

max

Huh? Only $125?? No more like $500 per year per patient. If I can hire a physician to work for $125 I will invite them over to cut my grass for the year for that price. Wow we physicians work for peanuts.

Dr. J

I agree that it should simply be a question of market based economics. Running a primary care practice is a business in the same way that running an accounting, dental, or law office is a business. Dentists are already adept at this, they can easily tell you what any procedure or visit will cost and what your insurance will pay and give you a balance of what it will cost you.
The first step is to set an hourly rate that includes your time and your office staff and overhead. My personal hourly rate is $500, which is the same as my lawyers and a bit more than my accountants, when you bill for non-insured services bill by the tenth of an hour. Display your office rate, and give your secretary a rate for all recurring non-insured services that you perform. Have your secretary question each person who makes an appointment about non-insured services and provide cost estimates before appointments. For other forms and services provide an estimate before taking on the task (ie. letters for lawyers).
If you wish provide options for an annual fee for bundled services, such as basic forms for school and work, Rx refills, and phone calls, and perhaps a family bundle that includes an entire family for a discounted rate.
If you wish to continue to provide care for patients who will not pay you (ie. pro bono work) then talk to your accountant about whether you can deduct these non-recoverable bills as business losses.
Once you are effectively billing for your time you will be able to become more efficient for your patients, you will be able to fill a form in right away (no more 3 hours of forms after all the patients are gone) because it is compensated time.
Every other profession uses this concept in billing. If your not sure phone your accountant and ask, then pay his bill for a tenth of an hour for your phone call afterwards.
Remember if you don’t value your time no one else will value your time.

DO Student Doc

Dr. J,

I understand that more docs are starting to use this model (a la cart medicine) with some success. I think that it has potential to work well for both sides. The doc gets to charge for all the work he does (based on his advertised price) and the patient gets to have no surprises in his bill.

gerridoc

Twenty seven years ago, when I started in private practice IM, patients paid directly for their office visits ($35 to 40 for a 15 min visit), and revenue from office and hospital visits covered our overhead for a 2 physician practice and our salaries. So we could afford to fill out forms, call in prescriptions, pay the salaries of our 3 employees (including an RN), and not worry about “uncompensated care.” While most physicians don’t want to “nickel and dime” our patients, we cannot afford to maintain a small business anymore. I would like to know how anyone could justify staying in business while facing a 21% reduction in pay from Medicare.

gerridoc

Full disclosure: I am no longer in clinical practice.

MarylandMD

Interesting discussion. I have been going back and forth on these kinds of ideas in my head for a while. The arguments both pro and con have at least some merit. I don’t know yet where I stand, but here are some thoughts:

1) If we charge fees for every little “extra” service, our patients may soon love us as much as they “love” the banks, the phone companies, and the airlines. In our economy, extra fees often seem to be used as a trick to get people to pay more money unintentionally.

2) The original idea has merit but misses the point. You won’t “save” primary care by generating a bit more income from all the extras that we do. The physical and emotional burden of all the extras is what is really killing primary care. Medical students do their ambulatory rotations and see primary care physicians who are rushed and frayed, awash in forms, test results, preauthorizations, referrals, refills, coding and other tasks that take away from our one-on-one time with patients. So the students figure, heck, if primary care gets so little time with patients, why not just go into dermatology or ophthalmology where you get about the same amount of “quality” time with patients, work much better hours, and earn a lot more money? We could never clear enough cash from those burdens that Medicare considers “extra” to allow us to shift the balance back towards a lot more time with patients and a workflow that at the end of the day has us feeling fulfilled instead of drained.

Anon

I got a phone message from a patient I haven’t seen in 2 years asking me to refill 2 medications and mail them to him (ie. my stamp). Asked him to come for an appointment and he faxed me his physical exam from work (high powered executive) and assured me his cardiologist had his BP under control. We told him to make an appointment or get the Rxs from his cardiologist or whoever did his work physical. Why did he call us? I’m sure it’s because we actually answer the phone and take action on our messages. That’s the service we provide for paying customers. He will never get the message to his cardiologist and he knows it.

Dr. J

Anon: This is a good example of how non-insured services are missed business opportunities. This guy is a good patient, he follows up with his cardiologist and has his BP under control, he’s gainfully employed. He’s a good patient to have in your practice. Instead of a business opportunity you have a conflict on your hands, that’s a bad use of your time (it’s stressful and pays nothing).
It would be a good idea to have your secretary call him back and tell him that Rx refills not at an appointment are a non-insures service and subject to private payment. Because he has not seen you in a while you will need to review the records from the cardiologist, call his pharmacy to ensure the dosages of the medication are correct. Then courier him the Rx in a signature required envelope. Invoice the shipping and handling as an item in your bill.
In this scenario the bill is 3 10ths of an hour for records and pharmacy review and Rx prep. at $500 per hour = $150 plus shipping and handling.
Wouldn’t it be better to have $150 than to have this conflict with your patient?
If the patient does not want to pay this, no worries it is a free market then can get care anywhere…

Max

Dr. J I like how you think. Can you tell me how you inform your patients up front that non-appointment refills will be charged? Do you post a sign?

jill

Dear Anonymous Primary Care Physician Who Can’t Pay Your Bills,
Here’s a thought: Get smaller bills. Trim your costs. Be thrifty. Buy a smaller house… a bread-and-butter car. Move to a less expensive town. Use different settings on your heat and air-conditioning. Take shorter showers. Buy less meat. Drink less alcohol. Don’t go out to eat as much. Do I really have to sit here and offer ways to cut your expenses? Are you that far removed from the real world that you can’t come up with ideas on your own? If social workers who are single mothers can find a way to live on $40k/year in major cities, I’m willing to bet it would be possible for you to trim your expenses to the point that you would be able to pay your bills. Or you could just continue thinking INSIDE the box, leave the profession you worked hard to enter and then complain about it on blogs. That’s also an option.

jill

Dear Primary Care Internist,
“I think for most insurances doctors are doing patients a tremendous favor by accepting insurance assignment, basically gambling on if and how much they’ll be paid.”

Really? Well, then stop. Get back to us in 6 months… if you’re still in business. You aren’t doing anyone a favor by accepting insurance assignment. You’re earning a livelihood. That’s the business model of most of medicine. Unless you serve a very wealthy clientele who can pay for your services out-of-pocket on a daily basis, the business model you’re using is the business model that will keep you viable. You can keep thinking that by accepting insurance, you are being “altruistic”, but you are making a huge cognitive error that will ensure the persistence of your misery and unhappiness. You’re no more altruistic than the guy repairing my house. He, too, is earning a living with a business model that is socially accepted as the norm. You just made the decision to toil away in school longer than he did. And that was YOUR decision.

DO Student Doc

Jill wrote:

“Well, then stop [taking insurance]. Get back to us in 6 months… if you’re still in business.”

Actually, more and more docs are doing this this and their practices are thriving. It seems that when they are well paid, they can actually spend more than 15 minutes with a patient, they can afford to hire quality staff, maintain a functional facility and give the patient all-around better care.

We had an orthopedic surgeon speak to my anatomy class last year. At the end of his talk, he put up a graphic that showed his actual charges for a common wrist surgery and the fee paid by the various insurances he took. None were more than 75% of his actual charges (which are based on his costs, just like every other business person) and Medicare was less than 50%!! At that rate, he doesn’t even make enough to pay overhead AND he works for free.

Having managed a construction company for a time before coming to med school, I can tell you that NO OTHER industry tolerates this sort of thing. If you need me to install a septic tank for you, here is my estimate and here is my final bill. Period. Only in medicine do highly-qualified, well-educated professionals sell their services so cheaply and yet the public still complains. It’s actually quite shameless.

You try going to school for 12 years, incurring between $300,000 and $500,000 in student loans and then have folks complain because you would like to make enough to pay your staff, pay for a decent, attractive, functional facility, and still take home enough to feed your family AND pay off your student loans.

If your response is, “Well, you’re the one who decided to do this,” then your sense of entitlement is beyond shameful! Try taking that attitude to your local contractor or lawyer or even restaurant owner and see how far it gets you.

jill

By the way,
“I think most would find that a small price to pay to keep their doctor’s doors open.”
Really? Why should I care if your doors are open if the large hospital group down the road doesn’t charge me an administrative fee? I don’t. You make more money than I do. I fill out paperwork, answer emails, make phone calls, review documents, etc., too. I don’t get paid extra for them. I make a salary. These responsibilities are not provided for free. They are included as part of my salary. You make more money than me and you are complaining about providing “free” services? Last time I checked, writing and refilling prescriptions was part of patient care? Isn’t that what your profession does… take care of patients? Last time I checked, talking with patients’ insurance companies was part of getting reimbursed AND part of making sure the patient is able to have access to the care that he or she needs. Isn’t that part of staying in business and doing your job responsibly? In fact, isn’t that a COST of doing business? You people think that if there isn’t a charge code for every activity that occurs during every second of every workday, you are providing the activity for free. You need to reframe your thinking because your current frame is severely off-kilter. Everyone emails at work. Very few are paid extra for it. Same with making phone calls. Same with filling out paperwork. So, no, if you feel the need to charge me $125 for picking up the phone, I really could not care less whether or not you stay in business. I don’t have $125 to give you. I can barely afford the cost of my premiums and co-insurance. My heard does not bleed for you. You turn it to stone.

Anonymous

This is precisely why the general public does not understand the cost of medicine. The numerous administrative tasks that consume a majority of a doctor’s time need to be compensated because it doesn’t leave any time to see patients. When exactly do you expect, after an eight hour work day, a doctor to take care of the insurance related tasks which generally can’t be done when the insurance company is not open (aka normal business hours) ?

In addition, despite your salary, you can leave things until the next day. In fact, after an eight hour day you can just leave without consequence. If a doctor leaves a stack of lab reports, radiology reports, or patient messages on his desk/in his EMR then something bad could happen (any number of things).

Reimbursement does NOT include administrative tasks, as much as you believe it does. Money that the doctor gets from the insurance company is specifically for the office visit. Anything else is ancillary services. The bottom line is that, just like a lawyer who bills his time when he is working on a case, when working on patient care related activities there should be a way to get paid for it. Most of the time the doctor is seeing patients and even then (in primary care) they are there until many hours later doing paperwork.

Sure, people do paperwork, phone calls, emails at work. Guess what, in our society patient’s expect to be able to have an entire office visit over the phone and if that’s the expectation it should be billable. The same is the case for email. Why ? During these conversations, medical advice is being given and whenever that is happening the doctor is liable for what is being said – he is doing work. Again, the law analogy applies (i.e. a lawyer charges for these things as well – don’t see anyone complaining).

Vox Rusticus

Jill:

I work to pay the salaries of people like you. Unlike you, I don’t get paid a salary. In fact, if it is a bad month, or insurance companies are in the denying without cause mode, I might have to wait longer than I’d like to get paid.
The people I employ get paid regardless of the piecework they do, a little or a lot. But they get paid for every hour they work. I, on the other hand, as the owner and boss man, I get paid only when I do things that the insurance companies regard as a billable service. Things that aren’t billable, they aren’t paid for as medical services, no matter how much of my time they take (unlike you, for whose time you would expect to be compensated.) Some of that stuff I can’t attach to a particular patient’s account. But some of it I can, and if it really isn’t directly related to the office visit, or if it is being done in lieu of a paid encounter, well, I have as much a right to try to be paid for that work as you do for yours.

Now you say you will go down the street to the big nonprofit (laughter here) and get your freebies from them. Good on ya if that works. All the nonprofits I see around are pretty flush (definition of a nonprofit is that you don’t have to pay taxes and share your profits with shareholders–you can pay them all as bonuses to senior management,) so maybe that’ll work for you. But nothing is carved in stone that way, so what is to keep them from doing the same thing? Really nothing.

Dr. J

Wow, what a great conversation!
A couple of points….
1) Jill, your posts are a good example of how a free market system would/should work. I value the hourly rate of my office at $500 per hour, while you believe that is too much. No problem, and no need for bad feelings towards each other, you can opt to not see me in favor of another doctor. You suggest trimming overhead costs and that is definitely a way to optimize income, for doctors who only bill insurers this is the only way to optimize income. Trimming overhead has consequences though, for both the physician and the patient. It means a not so nice office in a not so nice area of town, it means I will be more rushed with you because I will need to see more patients, and it means I will have less specialized support staff (like RNs). There is absolutely nothing wrong with this practice style, and it is a good fit for a lot of people, I just wouldn’t choose to work that way.

2) Max: You should be able to give each patient a booklet with the rules of the practice telling them what they can expect and what their options are. It should have all the information about your on call system, office hours etc.
If it’s a new practice you tell your patients in person at their first appointment so that they can choose to use your practice or not. If you are transitioning your practice you send a letter to each patient explaining the changes, and then review with them at their next visit. You will loose some patients, but no problem you probably have too many patients in your practice to allow it to run properly anyways. The idea is that because you will be compensated for all of your time you will be able to run on time and get everything done as you go through the day. Instead of a long form for return to work to be filled in at the end of the day, you schedule this within your day.
The real idea is not to make more money, it’s to have a predictable and controllable life and to leave on time at the end of the day. (If you are making changes why not also consider going to at least 50% of the day as same day bookings, a different conversation but it will improve your practice life immensely and you will see a much better mix of cases).

3) Student DO Doc, There are many different modes of practice, don’t think you have to join a dysfunctional group when you finish, make your practice work for you.
I recently heard about an ultra low overhead practice idea that would work well in urban areas. The idea is that if you live in a very densely populated area you set up a practice that only does home calls, and you only take patients who live within a very small radius (make sure they know that if they move away they need a new MD). Charting is on an ipad using LifeRecord (an online EMR which I am not affiliated with). I think that would be a great idea for some physicians.
Overall the most important things are to value your own time and design your practice so that it is predictable and allows you to go home on time at the end of the day and have a life outside of medicine, otherwise you will last but a brief time and then quit like so many others.

Primary Care Internist

i DO NOT get a salary. In fact I pay a small salary to my part-time employee. And I can’t tell her that i’m only paying her x% of my insurance reimbursement for the week, forcing her to take a gamble. Most people (like you and her) expect and receive a relatively constant salary no matter what happens in the bigger picture. But as you’ve shown you don’t understand, small practice doctors do not.

And again, while i’m sitting in the office returning faxes to express-scripts for a patient i haven’t seen in a year, that’s time that I can’t see patients and generate a billable service. Should I tell my employees that i’m not paying them for that time??? I wish your employer would tell you that.

And good luck with that hospital-based clinic care. Good luck with getting timely lab results, getting reasonable follow-up, personal attention, or even seeing a board-certified physician. Most likely, you won’t get any of this from such places. But those clinics actually get HIGHER payment from insurers and medicaid, AND enjoy non-profit status.

Really, should everyone work for the same income? Sure a social worker making $40k in NYC figures out how to make that work. But by your logic, shouldn’t a nurse’s aide or high school graduate be making that much? After all, it was that social worker’s “decision to toil away in school longer than he did”.

Anonymous

dear primary care internist,
im a fam med doc in solo med and here is what i do about some chronic problem issues in the PCP’s office:

about refills: i just dont refill anyones medications with greater than a year from their last appt. i give the faxed refill request from the pharmacy back to my medical asst and tell them to call the patient. i script her to say that this medical condition and good medical care requires yearly follow-up. until an apt, no refill. but to show the patient we have some compassion and ability to work with peoples busy schedule, my medical assistant might say on the phone to the patient “if you at least MAKE the apt today for sometime in the next 2-3 weeks, the doctor can give you ONE month of a refill to tide you over till you get into the office, but we can only do this once.” after that NO more refills till seen by the MD. i might have lost a few patients over the years, but those are the ones i dont want anyway.

about no-shows: i charge a $40 no-show fee. if someone has a no-show and then i get a refill request, my m.a. calls the patient to get a credit card # to pay for the no-show FIRST. no refills til that bill is paid. sure, i might have lost a patient or two (i cant recall losing even one actually), but no-shows are unacceptable. and im thinking of increasing the fee to $60. before i initiated a no-show fee i had about 25% no-show. now its about 5-7%. which is manageable, but i still lose revenue.

ive been getting more clear with my boundaries and limit setting for my practice and it has improved some things alot.
good luck.

TrenchDoc

MB
The person who treats himself has a fool for a patient.

With 32 years of clinical experience as an internest you want to see someone like me if you have a complex medical problem. just as I will honor you by not drawing assumptions or prejudging you, honor me by valuing my services.

Vikki

Physicians in private practice need to face the facts—as any service-oriented business you will keep customers (patients) and lose them based on your business practices. I like my GP but if she starts to bill me for ancillary services, or imposes a flat yearly fee then I’ll just change doctors to one who doesn’t do this.

Take my lawyer…..please. Just kidding. But a real-life example is when I chose Attorney Jane several years ago to represent me in a divorce. The divorce proceedings were quoted at a certain fee but then I was presented with a long list of additional fees that could be incurred. Read: I was nickel and dimed. Photo copies were charged $1 for the first page and $.50 per page thereafter. Phone calls were charged in 5 minute increments, etc. I practiced speed talking when I telephoned her to keep my cost down. When I needed legal services last year, I DID NOT return to Attorney Jane, although the divorce proceedings went well. Instead, I chose Attorney Sam who didn’t monetarily squeeze me; he quoted a flat fee for my case and that was that. He couldn’t determine exactly how much time he’d spend on the telephone with my case; he didn’t know exactly how many letters he would need to send on my behalf, yet he adhered to his flat fee. He was wonderful to work with and I trusted him. I’ve recommended him to friends.

I think it’s unreasonable in any segment of business to try and charge the customer for every nod of your head and blink of your eye. The reality is that in most businesses we work long hours over our daily base salary, hours that aren’t directly compensated.

Dr. J

Vikki this is exactly the sort of market based decision that should be happening in primary care, but is not allowed to because of the involvement of the insurance industry in the US, and the government in Canada.
You say you would not like to be nickel and dimed for everything and that is fair, in a real market system you would probably choose a primary care practice that charged you an annual bundled fee that set out a clear expectation of what services you should expect to be delivered and in what time frame and by who. I think most people who value seeing the same doctor regularly and who have one or more medical conditions that requires follow-up would agree with you and choose a practice with a fee bundle. Some people would prefer to be nickel and dimed though because they may view themselves as only occasional users of the medical system and think that this would be a more economically advantageous arrangement. For instance I suspect that in a real market system men under 45 would overwhelmingly choose a pay as you go plan rather than bundled services (since many men seem to view themselves as invincible).

The current model of primary care emphasizes patient volume, and patients seem to almost universally think that they wait to long for appointments, have appointments that are too short and can’t get all of their issues addressed. This is bad customer service on our part, but it is difficult to address because of the mechanism of funding for primary care. Many primary care docs carry case loads of 1500 to 2500 patients so it’s no wonder that many patients don’t feel that their primary doctor actually knows them.

Lets consider a couple of alternative models based on an annual fee bundle or retainer or a pay as you go plan and how these could alleviate some of these issues.

First lets consider a high end fee bundle. A doctor wants to provide absolutely supreme care to a small number of patients, he agrees to be personally available by phone 24/7 50 weeks of the year and to provide dedicated replacement coverage the remaining 2 weeks. He will always be available for same day appointments and is dedicated to both preventative health and active disease management. He always calls patients 2 days after an office visit to see how they are doing, he does home visits, and he has a registered nurse who works with him in his office who helps in patient care and education. Because he has an upscale clientele he rents a small office in a beautiful high-rise in a very affluent area, the office has beautiful ambience that enhances the patients visit experience. This first doctor wishes to make an annual before tax income of $275,000, and so he charges an annual fee of $5000 to each of the 100 patients in his practice: $100,000 for office overhead, $75,000 for his nurse and $50,000 for his secretary. In addition to making a good living and providing excellent care for the patients, this doctor has a very manageable life. Although he has chosen to always be on call he has a very small number of patients in his care so the burden of that call is far less than in a ‘typical’ practice.

A second practice wishes to serve a more mainstream population but the physician also wishes to make $275,000 per year. He is going to have a larger practice so can’t offer all of the same services as the physician above but he does agree to have a call system that is available 24/7/365 with telephone availability of one of 10 doctors in his group, he offers a limited number of same day appointments, and a guarantee to be seen within 1 week. Full physical exams require 1 month pre booking. He does not offer home calls, but does provide hospital visits at the local hospital on weekday mornings. He works in a shared group office with shared secretarial staff and one nurse per 3 physicians who provides some limited services like immunizations. He runs an evening clinic once per week to see people out of office hours.
His charges an annual fee of $1000 to each of the 400 patients in his practice; $125,000 for total shared office overhead.

A third doctor doesn’t like the bundled care model and still wants to make at least $275,000 a year so he sets up a clinic that is open to all and charges a flat fee of $75 per visit. He works 5 days a week and 40 weeks a year. He varies his office hours on different days. He has a secretary but no other office staff. He doesn’t provide any on call coverage or additional services. His clinic is in a cheap area of town with low rent. On average he sees 30 patients a day. He is fast but very nice, speaks multiple languages and patients find him on point and personable. He always addresses their presenting concern, but is less adept at screening tests and preventative care. He saw over 3000 different patients last year so he knows very few patients personally. His office overhead is $150,000.
($75x30x5x40-$150,000=$300,000).

These are 3 examples of practices based on the needs and wants of both physicians and patients and offering different services that suit different needs for different populations. In Vikki’s example above she would probably choose the second practice as it offers good care and good value and minimizes expense for non-essentials. As a young healthy man I would personally choose practice #3.
We can easily see how the current model where pcp’s take care of thousands of patients doesn’t allow them to provide any sort of personalized care, while the insurance industry’s value on patient volume prevents alternative models. By allowing a market system for primary care we could allow patients to choose practice models that would be a better fit for them, both personally and financially and this would lead to better satisfaction for both patients and doctors.